10
Hughston Benefits Guide
DENTAL | METLIFE
Premium Plan
Basic Plan
Dental Plan - MetLife
Annual Deductible Individual | Family Preventive Services
$50 | $150 $50 | $150
100%
100%
Your dental coverage is offered through MetLife for the 2024 plan year. Please review your plan summaries or policy for coverage information and full plan details.
Basic Services Major Services
80% 50% 50%
80% N/A N/A
Orthodontia (Child up to age 26) Annual Benefit Maximum Orthodontia Lifetime Maximum Out-of-Network Reimbursement
$3,000 $1,500
$1,500
N/A
90th UCR Premium Plan
90th UCR
Dental Rates (Bi-Weekly)
Basic Plan
Employee Employee + Spouse Employee + Child(ren) Family
$11.29 $18.90 $20.48 $27.30
$6.82 $11.34 $12.34 $16.27
Out-of-Network Reimbursement
Vision Plan - MetLife
In-Network
Eye Exam Lenses Single Bifocals Trifocals
$10 Copay
Up to $45
$20 Copay $20 Copay $20 Copay
Up to $30 Up to $50 Up to $65
$130 Allowance after $20 Copay*
Frames
Up to $70
VISION | METLIFE
Contacts Electve Medically Necessary
$130 Allowance $20 Copay
Up to $105 Up to $210
Frequency Exam/Lenses or Contacts/Frames 12/12/24 Months Vision Rates (Bi-Weekly) Employee $3.41 Employee + Spouse $5.57 Employee + Child(ren) $5.46 Family $8.98
Your vision coverage is offered through MetLife for the 2024 plan year. Please review your plan summaries or policy for coverage information and full plan details.
* Costco, Walmart and Sam’s Club: $70 allowance after $20 eyewear copay.
TELEMEDICINE | TELADOC Telemedicine is an affordable plan that gives you and your family 24/7/365 access to U.S. Board Certified Physicians who can consult, diagnose, and if needed prescribe medication over the phone or via video technology for many common and acute illnesses.
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